Quality Improvement

Postoperative atrial fibrillation (POAF) remains the most common complication following cardiac surgery—and a persistent challenge for clinicians seeking consistent, evidence-based management. In response, the Society of Thoracic Surgeons (STS) has released new clinical practice guidelines, now published in The Annals of Thoracic Surgery, outlining a comprehensive, surgery-specific framework for the prevention and treatment of POAF.

A Multidisciplinary, Evidence-Driven Effort

Co-led by Subhasis Chatterjee, MD, of Baylor College of Medicine, and Stefano Schena, MD, PhD, of Medical College of Wisconsin, the STS 2026 Clinical Practice Guidelines for the Prevention and Treatment of New-Onset Postoperative Atrial Fibrillation after Cardiac Surgery were developed through a multidisciplinary effort by the STS Workforce on Evidence-Based Surgery. The group evaluated contemporary evidence to generate practical, consensus-based recommendations focused specifically on the prevention and treatment of POAF after cardiac surgery.

A Phase-Based Framework Across the Surgical Continuum

The document establishes a phase-based framework spanning the preoperative, intraoperative, and postoperative periods. Drawing from randomized and observational studies, the panel graded recommendations using standardized methods aligned with American Association for Thoracic Surgery (AATS), European Association for Cardio-Thoracic Surgery (EACTS), European Society of Thoracic Surgeons (ESTS), and STS harmonization guidelines.

A central theme of the guidelines is transparency around uncertainty and a focus on meaningful patient outcomes. “One of the goals of these guidelines was not to promote a single dominant therapy, but to provide a structured, phase-based approach that can reduce unwarranted practice variation while still allowing clinical judgment,” said Dr. Chatterjee. He emphasized that POAF should be viewed as a marker of perioperative vulnerability rather than an isolated rhythm disturbance, helping to identify patients at higher risk for complications and future atrial arrhythmias. This perspective supports targeted surveillance and follow-up rather than reflexive escalation of therapy.

The guidelines also underscore that POAF is distinct from preexisting atrial fibrillation, with different mechanisms, natural history, and management implications. Core strategies include careful rhythm monitoring, early rate or rhythm control, and individualized anticoagulation decisions. At the same time, the document acknowledges ongoing uncertainty regarding optimal anticoagulation timing and duration, arrhythmia burden, and the role of adjunctive surgical interventions.

Addressing Uncertainty and Variability in Practice

Dr. Schena noted that the guideline development process highlighted the variability in clinical practice and the limitations of available evidence. “The time spent discussing and reviewing helped us recalibrate our stance and recognize how limited the evidence truly is for many commonly used interventions,” he said. While no single strategy eliminates POAF, he emphasized that its clinical impact can be reduced through a combination of measures applied across all phases of care. He also noted that the long-term implications of POAF in patients without prior atrial fibrillation remain uncertain and must be weighed against individual patient risk factors.

Together, these guidelines provide a pragmatic framework that clinicians can apply across the surgical continuum. By emphasizing evidence-based practices, acknowledging uncertainty, and discouraging ineffective interventions, the document aims to support informed clinical decision-making and improve outcomes for patients undergoing cardiac surgery.

Read the Annals article.

On Friday, Jan. 30, at 9:30 a.m., Stephanie Worrell, MD, of the University of Arizona, presented STS Perforation Guidelines during the "Esophageal Perforation Management" session. Her talk introduced a new Society of Thoracic Surgeons (STS) Expert Consensus Document designed to improve the diagnosis and management of esophageal perforation, a rare but potentially fatal condition.

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Esophageal perforation, often a complication of endoscopic procedures, requires early diagnosis, as mortality and morbidity increase if treatment is delayed beyond 24 hours. Despite advances in treatment, management remains inconsistent due to the condition’s rarity and limited clinical data.

To address this gap, the STS convened a multidisciplinary panel of thoracic surgeons and gastroenterologists, who reviewed studies from the past 14 years to develop consensus statements on diagnosis, treatment, and long-term care. For stable patients with confirmed perforation, the consensus supports endoscopic therapies when matched appropriately to anatomy and operator expertise. Surgical intervention remains essential for unstable patients or complex cases.

In her talk, Dr. Worrell discussed how the guidelines provide clarity in clinical scenarios that often prompt uncertainty. “These recommendations clarify when further investigation is appropriate and when it’s safe to observe or discharge,” she said. She notes that the guidelines are particularly valuable for conditions like spontaneous pneumomediastinum where further workup may be unnecessary. Additionally, there is now strong data for CT esophagrams and growing evidence for endoscopic approaches that are not yet used consistently.

During the Airway Issues session on Friday, Jan. 30 at 1:30 p.m., Joseph Nellis, MD, of Duke University Medical Center, will present the Richard E. Clark Memorial Paper, Impact of Preoperative Tracheostomy on Outcomes Following Congenital Cardiac Surgery: A Study of the STS Congenital Heart Surgery Database, at STS 2026. In this presentation, Dr. Nellis will examine how preoperative tracheostomy affects outcomes following congenital cardiac surgery, an area with limited prior data despite longstanding concerns about risk in this population.

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Congenital cardiac surgery patients with preoperative tracheostomy represent a small but increasingly recognized group with complex medical needs. To better understand how tracheostomy status influences surgical outcomes, Dr. Nellis and colleagues analyzed national registry data spanning a decade of congenital cardiac operations, comparing patients with preoperative tracheostomy to those without this airway history.

Overall, patients with preoperative tracheostomy experienced higher rates of postoperative complications, readmissions, and mortality compared with those without tracheostomy. Even after accounting for differences in baseline risk, preoperative tracheostomy remained associated with an increased likelihood of infection-related complications and early mortality, though it was not linked to longer hospital stays or higher overall morbidity.

In his presentation, Dr. Nellis will outline the implications these findings inform risk stratification and surgical planning for children with complex airway and cardiac disease. He emphasizes that while preoperative tracheostomy identifies a higher-risk patient population, it should not, by itself, exclude patients from consideration for definitive congenital cardiac surgery.
 

On Thursday, January 29, the Society of Thoracic Surgeons (STS), in collaboration with the International Society for Heart and Lung Transplantation (ISHLT), hosted the inaugural STS/ISHLT Lung Transplantation Symposium as part of the STS 62nd Annual Meeting. This full-day specialty session provided a practical, multidisciplinary review of contemporary lung transplantation, covering donor selection through long-term management with an emphasis on intraoperative decision-making and complex clinical scenarios.

“Through its practical, comprehensive approach, the symposium offered attendees an in-depth perspective on modern lung transplantation,” said organizing chair Kewal Krishan, MD. “The program equipped surgeons and care teams with strategies for both routine and highly complex cases.”

The program combined didactic lectures, live debates, and case-based panels to highlight advances in donor management, organ preservation, surgical techniques, and perioperative care. Attendees earned CME credits while engaging in detailed discussions of common challenges in lung transplantation surgery.

Sessions delivered a case-based overview across the operative spectrum—from donor management and organ preservation to complex intraoperative rescue. Faculty reviewed retrieval strategies in donation after brain death and circulatory death, surgical implantation techniques, perioperative anesthesia and hemodynamic management, and the use of ECMO or cardiopulmonary bypass. Advanced scenarios, including robotic, redo, and heart–lung transplantation, concluded with interactive discussions focused on real-world, high-risk cases.

As the population undergoing mitral valve surgery continues to age, the choice between repair and replacement has taken on new urgency. At the "Masters of the Mitral Valve" session on Thursday, Jan. 29 at 10:10 a.m., Dr. Allen Razavi of Cedars-Sinai Medical Center will address this issue in the Is Degenerative Mitral Valve Repair Superior to Replacement in Patients Aged >65 Years? presentation.

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Drawing from a large national cohort within the Society of Thoracic Surgeons Adult Cardiac Surgery Database linked with Medicare data, Dr. Razavi and his team compared long-term outcomes for patients aged 65 and older who underwent mitral valve repair with those who received mitral valve replacement. Their objective was to evaluate differences in survival, major complications, and the need for future mitral valve interventions across treatment strategies.

The study found that mitral repair was associated with significantly improved long-term survival compared with replacement, with benefits persisting across much of the older age spectrum. Patients who underwent repair also experienced lower rates of heart failure readmission, stroke, and major bleeding. While overall reintervention rates were similar between groups, repair patients tended to require earlier surgical reintervention, whereas replacement patients were more likely to undergo late transcatheter procedures.

Dr. Razavi will present findings showing how evolving treatment options and advances in repair techniques prompted the team to reassess outcomes in this population. The growth of transcatheter mitral therapies and improvements in surgical durability have heightened the need to revisit traditional assumptions about when repair should be favored over replacement.